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January 2015, Vol 3, No 1 - Inside Pediatric Health
Natalie Drummond, MD
Marc Drummond, PsyD, MBA

In clinical practice, sleep concerns associated with the use of stimulant medications for attention-deficit/ hyperactivity disorder (ADHD) are common. Parents have numerous concerns regarding the quantity and quality of their child’s sleep, as well as the known side effects of ADHD medications that interfere with sleep initiation and maintenance. It is key for community pharmacists and retail clinicians to understand these concerns and be able to address questions about possible solutions.

Diagnosis
The first concern expressed by parents and treating professionals when faced with iatrogenic sleep disturbances is the inappropriate overuse and reliance on stimulant medication in children who have not undergone a thorough diagnostic regimen.

In a recent article published in Pediatrics, investigators reported that 93% of patients with ADHD are prescribed medication only and not offered other treatment options.1 The study also revealed that only one third of healthcare providers diagnosing the disorder are following criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders.

The overreliance on nonspecific questionnaires by these healthcare providers results in many false positives, and cannot be used solely to make the diagnosis. Some of the other psychological conditions that mimic ADHD symptoms include anxiety, depression, learning disabilities, and spectrum disorders.1

Psychological testing under the supervision of a trained psychologist or physician consists of 6 to 8 hours total, usually in multiple sessions using standardized tests to ensure that a true executive function disorder exists. A concurrent medical evaluation to rule out medical diagnoses that can mimic ADHD symptoms should be completed. Organic sleep disorders, including restless legs syndrome, sleep apnea, and neurologic diseases such as epilepsy and developmental abnormalities, should be ruled out. A multidisciplinary team of both medical and psychological providers is vital to a proper diagnosis.

Treatment
Physicians have limited options when asked to help with sleep problems. Many parents are reluctant to give their children a prescription for a sleep disorder in addition to ADHD medication. The most common over-the-counter medications offered include antihistamines, melatonin, and lavender essential oil-based products.

Parents who choose a first-generation antihistamine for their children may be unaware that they cause significant performance deficits, including attention, vigilance, working memory, and speed, the following day.2 The antagonism between medications results in a treatment quagmire: use of an antihistamine helps with sleep initiation, but quality of sleep is poor, causing deficits in function the following day.

Melatonin has been used heavily in adults and pediatric patients with sleep and iatrogenic issues. Most common dosages of melatonin available in pharmacies are too high as a starting dose for pediatric and geriatric patients (3-10 mg). The human body normally produces <0.3 mg of melatonin per day and is sensitive to exogenous suppression. Although high doses of melatonin can be effective, it can perpetuate disrupted sleep by suppressing endogenous melatonin production through feedback inhibition and carry a higher risk of side effects. High doses of melatonin can also cause derangement of non-rapid eye movement sleep, leading to nightmares and night terrors in chronically sleep-deprived children; a few cases of seizures in neurologically compromised children have been documented.3 The pediatric and geriatric recommended dosage is 0.5 to 1 mg nightly, which can be difficult to locate in retail pharmacies.4 At the recommended dose of 0.5 mg, melatonin stimulates rather than suppresses the pineal gland to create more melatonin to aid in the restructuring of the sleep cycle.

Iron deficiency, specifically low serum ferritin, has been implicated in children with ADHD and impaired sleep. Serum concentrations of <45 µg/L have been associated with abnormal movements in sleep, including restless legs and sleep-wake transition disorders in patients with ADHD.5 A simple blood test and replacement with elemental or heightened dietary iron has been helpful to achieve desired serum ferritin levels and re-establish normal sleep-wake cycles.

Other Options to Consider
Essential oils are becoming very popular, and various oils have been shown to have calming effects in children. Chamomile, ylang ylang, and lavender have a long history of inducing sleep.6 Chamomile flowers can be steeped for a pleasant tasting tea, and essential oils such as lavender can be diffused to help create an atmosphere conducive to sleep. Concerns regarding the androgenic effects of lavender have made diffusion the delivery method of choice in pediatric patients.7

Other herbal preparations used in adults have limited efficacy data and, to our knowledge, no safety data in children. Valerian and hops have been used for centuries but their effectiveness as sleep aids has not been validated.8 However, a meta-analysis evaluating the usefulness of the valerian root concluded that valerian could improve the quality of sleep without side effects.9 The challenge with these alternative treatment options, compared with pharmacologic preparations, is that not a great deal of consistent research or standardized products are available. One systematic review concluded that valerian was safe but not clinically efficacious for insomnia.10

Kava has also been used as a sleep aid, although most of the research pertains to its use as an anxiolytic with actions similar to those of benzodiazepines.11 Although not mediated through the benzodiazepine binding site on the GABA receptor, kava may act on limbic structures, promoting anxiolysis without sedation. There have been reports of liver damage and failure from hepatotoxicity in individuals who used kava-based products or supplements, making practitioners wary of its use.11

Known Triggers of Sleep Disorders
There are numerous studies indicating that the blue light given off from the screens of common devices such as iPods, computers, and televisions simulates daylight, which confuses the pineal gland and throws off the natural sleep cycle.12 In children who are experiencing sleep problems, it is recommended that all screen time be cut off 2 hours before their expected bedtime.13 In older children where educational requirements necessitate computer use, there are programs available that naturally dim computer screens to avoid pineal interference, as well as blue light–blocking glasses and screen filters.14

The growing popularity of energy drinks has increased their availability to children and led to increased use in the teenage population.15 Counseling patients regarding their daily caffeine intake and caffeine use within the last few hours before going to sleep are an integral part of treatment for insomnia.

Mind and body practices (eg, guided meditation and progressive relaxation) are often helpful, free, and readily available through the Internet. A growing catalog of online and print resources for each age-group is an easy resource for parents to obtain and use.

It is also important to counsel patients to have a standard sleep ritual—consistent bedtimes and waking times are helpful. In addition, patients should aim to follow the same pattern for preparing for sleep each night, such as showering, reading a book for half an hour, meditating, and eventually turning the lights out.

Follow Up with a Pediatrician
If the child continues to have sleep problems after multiple interventions, it is important that he or she follows up with his or her pediatrician to rule out any other sleep-related issues and to discuss the risk–benefit of stimulant medication for ADHD.

Parents who have children with sleep problems are often experiencing sleep deficits themselves. It would be beneficial to encourage the parents to follow the same suggestions given to the child so that everyone in the family can have a good night’s sleep.




References

  1. Epstein JN, Kelleher KJ, Baum R, et al. Variability in ADHD care in community-based pediatrics. Pediatrics. 2014;134:1136-1143.
  2. Kay GG. The effects of antihistamines on cognition and performance. J Allergy Clin Immunol. 2000;105:S622-S627.
  3. Jan JE, Reiter RJ, Wasdell MB, et al. The role of the thalamus in sleep, pineal melatonin production, and circadian rhythm sleep disorders. J Pineal Res. 2009;46:1-7.
  4. Hughes RJ, Sack RL, Lewy AJ. The role of melatonin and circadian phase in age-related sleep-maintenance insomnia: assessment in a clinical trial of melatonin replacement. Sleep. 1998;21:52-68.
  5. Cortese S, Konofal E, Bernardina BD, et al. Sleep disturbances and serum ferritin levels in children with attention-deficit/hyperactivity disorder. Eur Child Adolesc Psychiatry. 2009;18:393-399.
  6. Wheatley D. Medicinal plants for insomnia: a review of their pharmacology, efficacy and tolerability. J Psychopharmacol. 2005;19:414-421.
  7. Kemper KJ, Romm AJ, Gardiner P. Prepubertal gynecomastia linked to lavender and tea tree oils. N Engl J Med. 2007;356:2541-2544.
  8. Salter S, Brownie S. Treating primary insomnia - the efficacy of valerian and hops. Aust Fam Physician. 2010;39:433-437.
  9. Bent S, Padula A, Moore D, et al. Valerian for sleep: a systematic review and meta-analysis. Am J Med. 2006;119:1005-1012.
  10. Taibi DM, Landis CA, Petry H, et al. A systematic review of valerian as a sleep aid: safe but not effective. Sleep Med Rev. 2007;11:209-230.
  11. Rowe A, Zhang LY, Ramzan I. Toxicokinetics of kava. Adv Pharmacol Sci. 2011;2011:326724.
  12. Figueiro MG, Wood B, Plitnick B, et al. The impact of light from computer monitors on melatonin levels in college students. Neuro Endocrinol Lett. 2011;32:158-163.
  13. Burkhart K, Phelps JR. Amber lenses to block blue light and improve sleep: a randomized trial. Chronobiol Int. 2009;26:1602-1612.
  14. Wood B, Rea MS, Plitnick B, et al. Light level and duration of exposure determine the impact of self-luminous tablets on melatonin suppression. Appl Ergon. 2013;44:237-240.
  15. Owens JA, Mindell J, Baylor A. Effect of energy drink and caffeinated beverage consumption on sleep, mood, and performance in children and adolescents. Nutr Rev. 2014;72 (suppl 1):65-71.

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